CH-100 Request for Civil Harassment Restraining Orders Clerk stamps date here when form is filed. Read Can a Civil Harassment Restraining Order Help Me? (form CH-100INFO) before completing this form. Also fill out Confidential CLETS Information (form CLETS-001) with as much information as you know. 1 Person Seeking Protection a. Your Full Name: Age: Your Lawyer (if you have one for this case): Name: State Bar No.: Firm Name: b. Your Address (If you have a lawyer, give your lawyer's information. If you do not have a lawyer and want to keep your home address private, you may give a different mailing address instead. You do not have to give telephone, fax, or e-mail.): Address: City: Telephone: E-Mail Address: State: Fax: Zip: Court fills in case number when form is filed. Fill in court name and street address: Superior Court of California, County of Case Number: 2 Person From Whom Protection Is Sought Full Name: Address (if known): City: State: Zip: Age: 3 Additional Protected Persons Yes No If yes, list them: a. Are you asking for protection for any other family or household members? Sex Age Lives with you? How are they related to you? Full Name Yes Yes Yes Yes No No No No Check here if there are more persons. Attach a sheet of paper and write "Attachment 3a--Additional Protected Persons" for a title. You may use form MC-025, Attachment. b. Why do these people need protection? (Explain below): Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of paper or form MC-025 and write "Attachment 3b--Why Others Need Protection" for a title. This is not a Court Order. Judicial Council of California, www.courts.ca.gov Revised January 1, 2017, Mandatory Form Code of Civil Procedure, §§ 527.6 and 527.9 Request for Civil Harassment Restraining Orders (Civil Harassment Prevention) CH-100, Page 1 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case Number: 4 Relationship of Parties How do you know the person in 2 ? (Explain below): Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of paper or form MC-025 and write "Attachment 4--Relationship of Parties" for a title. 5 Venue Why are you filing in this county? (Check all that apply): a. The person in 2 lives in this county. b. c. I was harassed by the person in 2 in this county. Other (specify): 6 Other Court Cases a. Have you or any of the persons named in 3 been involved in another court case with the person in 2 ? Yes (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) No If yes, check each kind of case and indicate where and when each was filed: Filed in (County/State) Year Filed Case Number (if known) Kind of Case Civil Harassment Domestic Violence Divorce, Nullity, Legal Separation Paternity, Parentage, Child Custody Elder or Dependent Adult Abuse Eviction Guardianship Workplace Violence Small Claims Criminal Other (specify): b. Are there now any protective or restraining orders in effect relating to you or any of the persons in 3 and the person in 2 ? No Yes If yes, attach a copy if you have one. 7 Description of Harassment Harassment means violence or threats of violence against you, or a course of conduct that seriously alarmed, annoyed, or harassed you and caused you substantial emotional distress. A course of conduct is more than one act. a. Tell the court about the last time the person in 2 harassed you. (1) (2) When did it happen? (provide date or estimated date): Who else was there? This is not a Court Order. Revised January 1, 2017 Request for Civil Harassment Restraining Orders (Civil Harassment Prevention) CH-100, Page 2 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case Number: (3) How did the person in 2 harass you? (Explain below): Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of paper or form MC-025 and write "Attachment 7a(3)--Describe Harassment" for a title. (4) Did the person in 2 use or threaten to use a gun or any other weapon? Yes No (If yes, explain below): Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of paper or form MC-025 and write "Attachment 7a(4)--Use of Weapons" for a title. (5) Were you harmed or injured because of the harassment? Yes No (If yes, explain below): Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of paper or form MC-025 and write "Attachment 7a(5)--Harm or Injury" for a title. (6) Did the police come? Yes No Yes No If yes, did they give you or the person in 2 an Emergency Protective Order? If yes, the order protects (check all that apply): a. The person in 2 c. Me b. Attach a copy of the order if you have one. b. Has the person in 2 harassed you at other times? Yes The persons in 3 No (If yes, describe prior incidents and provide dates of harassment below): Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of paper or form MC-025 and write "Attachment 7b--Previous Harassment" for a title. This is not a Court Order. Revised January 1, 2017 Request for Civil Harassment Restraining Orders (Civil Harassment Prevention) CH-100, Page 3 of 6 American LegalNet, Inc. www.FormsWorkFlow.com Case Number: Check the orders you want. 8 Personal Conduct Orders I ask the court to order the person in 2 not to do any of the following things to me or to any person to be protected listed in 3 : Harass, intimidate, molest, attack, strike, stalk, threaten, assault (sexually or otherwise), hit, abuse, destroy a. personal property of, or disturb the peace of the person. Contact the person, either directly or indirectly, in any way, including, but not limited to, in person, by b. telephone, in writing, by public or private mail, by interoffice mail, by e-mail, by text message, by fax, or by other electronic means. c. Other specify): Check here if there is not enough space for your answer. Put your complete answer on the attached sheet of paper or form MC-025 and write "Attachment 8c--Other Personal Conduct Orders," for a title. The person in 2 will be ordered not to take any action to get the addresses or locations of any protected person unless the court finds good cause not to make the order. 9 Stay-Away Orders a. I ask the court to order the person in 2 to stay at least (1) (2) (3) (4) (5) (6) (7) Me The other persons listed in 3 My home My job or workplace My school My children's schoo